Chimp Attack Victim, Charla Nash gets Face Transplant

Many of you no doubt remember the story of Charla Nash. Charla was the friend of a woman who kept 200 pound chimpanzee Travis as a pet, who, in February 2009, savagely attacked her without warning. Nash was left blind, with severe facial deformities and without both hands. Despite the devastating injuries, Nash survived and became an inspiration for many, telling her story on Oprah and the Today show.

It was reported today that Nash has undergone a face transplant at Boston’s Brigham and Woman’s Hospital. During the 20 hour procedure, a team of physicians replaced Nash’s nose, lips, facial skin, facial muscles and nerves. A double hand transplant was also performed, however the hands did not do well and had to be removed.

In the past the only way to fix a severe facial disfigurement was to use skin grafts. This involved taking pieces of healthy skin from elsewhere on the body or from a cadaver and placing them over the missing parts of the face. Although a skin graft may cover a defect, they can’t really restore the appearance or movement to the affected area.

The world’s first partial face transplant on a living human was carried out in November 2005 in France. Isabelle Dinoire underwent surgery to replace her original face that had been mauled by her dog. The first facial transplant in the United States was at the Cleveland Clinic in December 2008. This operation was the first facial transplant known to have included bones, along with muscle, skin, blood vessels, and nerves. The woman received a nose, most of the sinuses around the nose, the upper jaw, and even some teeth from a brain-dead donor.

How is a face transplant performed?

A great of preparation must be done before a face transplant is considered. Potential recipients are carefully screened physically and psychologically to make sure they will be able to handle the physical and emotional demands that the procedure will entail.

The donor must also be carefully selected. The facial tissues must still be attached to the circulation of a “living” donor who is brain dead with no chance of recovery. Once the blood vessels are cut, the countdown clock starts and the tissues need to be transplanted as soon as possible to ensure the best results. A special test, called a HLA test is performed on the tissue of the donor which characterizes the specific proteins on cells that stimulate the body’s immune system. The closer the HLA profile of the donor and the recipient, the less likely the tissue is to be rejected. The donor face is also matched for skin color and age of the skin.

The recipient of the face transplant will be worked on by rotating teams of doctors who will prepare the area for the surgery. Using microscopic surgical techniques the tiny blood vessels of the donor and recipient are sewn together to restore blood flow to the tissues. Bony structures may need to be pinned in place. Nerves and muscles are also connected. Finally, the skin is laid over the patient and sewn in its final position.

Interestingly, according to the Face Transplant team at Brigham and Women’s Hospital, a second small procedure is done at the same time. A small patch of the donor’s skin is transplanted on the chest or abdomen of the recipient. This area of skin will hopefully behave like the skin of the transplanted face and, if necessary, can be biopsied to look for signs of rejection, minimizing the need to biopsy the new face.

Like all transplant recipients, a face transplant recipient will need to take lifelong immunosuppressive medications to keep their immune system from rejecting the transplant. These medications can increase the risk of infection in these patient, as well as the risk of diabetes and cancer.
The big question about face transplants that everyone asks is whether the face transplant recipient look exactly like the donor? The answer is no. How the face looks is not defined solely by the skin — the underlying bone,fat and muscle structure are also important factors. After the procedure, the patient will probably look like a combination of themselves and the donor.

Michele R. Berman, M.D. was Clinical Director of The Pediatric Center, a private practice on Capitol Hill in Washington, D.C. from 1988-2000, and was named Outstanding Washington Physician by Washingtonian Magazine in 1999. She was a medical internet pioneer having established one of the first medical practice websites in 1997. Dr. Berman also authored a monthly column for Washington Parent Magazine.

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